What is the recommended treatment for a 77-year-old female with a history of atrial fibrillation (AFib) and elevated brain natriuretic peptide (BNP) level?

Management of Atrial Fibrillation in a 77-Year-Old Female with Elevated BNP

For a 77-year-old female with atrial fibrillation and elevated BNP of 308.8 pg/mL, the recommended treatment should include oral anticoagulation, rate control medication, and management of underlying heart failure with diuretics and appropriate heart failure therapy.

Risk Assessment and Anticoagulation

The patient has a high risk of thromboembolism based on:

• Age ≥75 years (2 points on CHA₂DS₂-VASc score)
• Female gender (1 point)
• Likely heart failure (suggested by elevated BNP)

This puts her at elevated thromboembolic risk, warranting anticoagulation:

• Oral anticoagulation is strongly recommended 1
• Options include:
  • Direct oral anticoagulants (DOACs) such as apixaban, which may be preferred due to better safety profile 2, 3
  • Warfarin with target INR 2.0-3.0 if DOACs are contraindicated 1
• If using warfarin, INR should be monitored weekly during initiation and monthly when stable 1

Heart Failure Evaluation and Management

The elevated BNP level of 308.8 pg/mL suggests underlying heart failure:

• BNP >100 pg/mL or NT-proBNP >400 pg/mL indicates possible heart failure 1
• Echocardiography is recommended to assess cardiac function, evaluate atrial size, and guide treatment decisions 1
• Diuretics are recommended to alleviate congestion and facilitate better AF management 1
• Based on echocardiography findings:
  • If reduced ejection fraction: ACE inhibitors/ARBs, beta-blockers, and SGLT2 inhibitors
  • If preserved ejection fraction: Blood pressure control and SGLT2 inhibitors 1

Rate Control Strategy

For controlling heart rate in AF:

• Beta-blockers, non-dihydropyridine calcium channel blockers, or digoxin are recommended for rate control 1
• Beta-blockers may be preferred if there is coexistent heart failure with reduced ejection fraction
• Digoxin is effective for controlling heart rate at rest and is particularly indicated for patients with heart failure 1
• A combination of digoxin with either beta-blocker or calcium channel blocker may be reasonable to control heart rate both at rest and during exercise 1

Rhythm Control Considerations

Given the patient's age and likely chronic nature of AF (suggested by elevated BNP):

• Rhythm control may be considered but is not mandatory in all patients 1
• Evaluation of AF-related symptoms should guide the decision for rhythm control 1
• If rhythm control is pursued, antiarrhythmic drugs or catheter ablation could be considered

Risk Factor and Comorbidity Management

Identification and management of risk factors and comorbidities is essential 1:

• Blood pressure control is recommended to reduce AF recurrence and progression
• Weight management if the patient is overweight or obese
• Glycemic control if diabetes is present
• Screening for sleep apnea if symptoms are present
• Tailored exercise program to improve cardiorespiratory fitness

Monitoring and Follow-up

• Regular assessment of rate control adequacy using ambulatory rhythm monitoring
• Periodic reassessment of thromboembolic risk
• Monitoring of BNP levels, as they can help track heart failure status and predict cardiovascular events 4
• BNP levels may decrease with successful treatment of both AF and heart failure 5, 6

Important Considerations

• Elevated BNP in AF patients predicts future heart failure events, even in the absence of clinical heart failure 4
• BNP levels are typically elevated during AF episodes (approximately 2.4-fold higher than during sinus rhythm) 6
• The combination of AF and elevated BNP significantly increases the risk of heart failure hospitalization or cardiovascular death 4